4 This report is available on the British Columbia Ministry of Health Services Mental Health and Addictions website: ISBN Date: March 19, 2009 British Columbia. Ministry of Health Services. British Columbia Program Standards for Assertive Community Treatment(ACT) Teams. ii ministry of Health Services

5 british columbia program standards for ACT teams ministry of health services The Standards for this program originated with those developed for the Program of Assertive Community Treatment (PACT) in the United States. Subsequently, the province of Ontario refined those guidelines for their purposes. The BC Program Standards for ACT Teams are largely adapted from the Ontario guidelines, as well as influenced by previous documents commissioned by the B.C. Ministry of Health Services, including the B.C. s Mental Health Reform Best Practices for Assertive Community Treatment (2000). The original PACT Standards were developed after almost 20 years of fieldtesting in various jurisdictions. A number of second and third generation studies of ACT programs in the U.S. have shown that ACT programs have not always achieved a similar degree of positive outcomes as the original PACT research. Typically, lack of strong fidelity to the ACT model is the demonstrated contributor to poorer results. Therefore, the British Columbia Program Standards for ACT Teams not only provides minimum Standards for program operations, but it also provides brief descriptions of the rationale for many of the ACT requirements which have been difficult for providers and administrators to implement. These ACT Standards highlight that ACT is a client-centred, recovery-oriented service delivery model. Client empowerment, involvement, and choice are fundamental to the principles and operation of individualized, collaborative and effective ACT service delivery. It also must be emphasized that these Standards are meant to be elaborated and built upon to address specific or local needs within Health Authorities. The purpose of these Standards is to define precisely: n for whom ACT is intended; n the required services; n the type of staff/numbers needed to competently provide the services; and n the intended benefits/outcomes for the clients receiving the services. Program Standards are used to establish costs and are used for program monitoring and compliance purposes. In addition, Standards must adhere to related federal and provincial legislation. Ministry of Health Services iii

6 BRITISH COLUMBIA PROGRAM STANDARDS FOR ACT TEAMS ACT Program Standards The British Columbia Program Standards for ACT Teams serves to guide ACT program start-up, implementation and ongoing operation by clearly defining the minimum program requirements. Successful ACT model implementation and demonstrated improvements in client outcomes are best accomplished by close adherence to the ACT Standards: i.e., serving persons with the most serious mental illnesses and substance use disorders; multidisciplinary staffing with at least one peer support; low staff-to-client ratios and intensive services; staff who work weekday, evening, and weekend/ holiday shifts and provide 24-hour on-call services; team organizational and communication structure; client-centred individualized assessment and treatment/service planning*; and up-to-date individually-tailored treatment, rehabilitation, and support services based on the original Madison, Wisconsin PACT research project. * The use of the term treatment/service planning reinforces that ACT teams provide treatment, rehabilitation and support services. Some teams may use different terminology such as recovery planning or care planning. There are fourteen sections of the ACT Program Standards. Throughout the Standards, text boxes will provide further explanation regarding program components. Please see the Appendix for definitions of terms used in the document. iv ministry of Health Services

11 I. INTRODUCTION Assertive Community Treatment (ACT) is a client-centered, recovery-oriented mental health service delivery model that has received substantial empirical support for facilitating community living, psychosocial rehabilitation, and recovery for persons who have the most serious mental illnesses, have severe symptoms and impairments, and have not benefited from traditional outpatient programs. The important characteristics of Assertive Community Treatment programs are: n ACT serves clients with serious mental illnesses and substance use disorders that are complex and who have very significant functional impairments, and who, because of the limitations of traditional mental health services, may have gone without appropriate services. Consequently, the client group is often over-represented among the homeless and in jails and correctional facilities, and has been unfairly thought to resist or avoid involvement in treatment. n ACT services are delivered by a group of multidisciplinary mental health staff who work as a team and provide the majority of the treatment, rehabilitation, and support services clients need to achieve their goals. The team is directed by a team coordinator and a psychiatrist and includes a sufficient number of staff from the core mental health disciplines, at least one peer support specialist, and a program/ administrative support staff who work in shifts to cover 24 hours per day, seven days a week to provide intensive services (multiple contacts may be as frequent as two to three times per day, seven days per week, and are based on client need and a mutually agreed upon plan between the client and ACT staff). Many, if not all, staff share responsibility for addressing the needs of all clients requiring frequent contact. n ACT services are individually tailored with each client and address the preferences and identified goals of each client. The approach with each client emphasizes relationship-building and active involvement in assisting individuals with serious mental illness to make improvements in functioning, to better manage symptoms, to achieve individual goals, and to maintain optimism. n The ACT team is mobile and delivers services in community locations to enable each client to find and live in their own residence and find and maintain work in community jobs rather than expecting the client to come to the program. Seventy-five per cent or more of the services Ministry of Health Services 1

12 I. INTRODUCTION are provided outside of the program offices in locations that are comfortable and convenient for clients. n ACT services are delivered in an ongoing rather than time-limited framework to aid the process of recovery and ensure continuity of caregiver. Serious mental illnesses are episodic disorders and many clients benefit from the availability of a longer-term treatment/service approach and continuity of care. This allows clients the opportunity to re-compensate, consolidate gains, sometimes slip back, and then take the next steps forward until they achieve their recovery goals. n ACT teams are required to have policies and procedures for each of the areas identified in the Standards. Once policies and procedures are in place, they maintain the organizational and service structure that supports the work and are useful in orienting and training new staff. 2 ministry of Health Services

13 II. Intake, Admission and Discharge Criteria and Process Admission decisions are based on considerations that include admission criteria, current caseload status, staff capacity, ability to manage risk in the community and overall team and organizational functioning. The ACT Program Standards establish written expectations for intake as well as admission and discharge criteria. The reasons for this are: n To ensure that clients with the most serious mental illnesses have top priority for ACT services; and n To prohibit people with severe mental illness from being inappropriately discharged or dropped from ACT services because of the complexity involved in engaging and finding effective interventions to achieve their recovery goals. A. Intake It is important that ACT teams find ways to expedite the entire intake and admission process. ACT teams are expected to take the initiative to develop collaborative intake processes with their relevant community and institutional referral sources to determine eligibility for admission, and to effectively prioritize and engage new clients. ACT teams must have clearly written and easily accessible, published admission criteria, consistent with these Standards and readily available to the community at large. During initial program implementation, each ACT team shall stagger client admissions (e.g., four to six clients per month) to gradually build up to full capacity. The rate of intake may be more gradual for reasons such as relatively inexperienced staff, where there are significant staffing gaps on the team or where teams are approaching full capacity. Intake occurs monthly until the team has reached capacity. Mature teams will continue to admit new clients if they are not at capacity due to discharges. Staff resources, organizational structures and processes must be adequate to safely admit clients with specialized needs. The rate of intake and proportion of caseload consisting of highly specialized populations (i.e., individuals with complex co-morbid disorders) should be carefully monitored. Ministry of Health Services 3

14 II. Intake, Admission and Discharge Criteria and Process B. Admission Admission Criteria The following criteria are to be used by an ACT team in selecting clients in the greatest need of ACT services: 1. Clients with severe and persistent mental illnesses that seriously impair their functioning in community living. Priority is given to people with schizophrenia, other psychotic disorders (e.g., schizoaffective disorder), and bipolar disorder because these illnesses more often cause long-term psychiatric disability and because of ACT s proven effectiveness with this population. Clients with other psychiatric illnesses are eligible depending on the level of the long-term disability. All ACT teams are encouraged to admit clients who meet ACT admission criteria, that is, individuals with severe and persistent mental illness. Clients that also suffer from other issues should similarly be admitted, particularly those with issues that would benefit from a coordinated treatment approach, including but not limited to: involvement with the criminal justice system at all levels, homeless clients, and those with developmental disabilities and substance use disorders. and 2. Clients with severe and persistent mental illness with significant functional impairments as demonstrated by at least one of the following conditions: a. Inability to consistently perform the range of activities of daily living required for basic adult functioning in the community (e.g., caring for personal business affairs; obtaining medical, legal, and housing services; recognizing and avoiding common dangers or hazards to self and possessions; meeting nutritional needs; maintaining personal hygiene) or persistent or recurrent difficulty performing daily living tasks except with significant support or assistance from others such as friends, family, or relatives. b. Inability to maintain consistent employment at a self-sustaining level or inability to consistently carry out the homemaker role (e.g., household meal preparation, washing clothes, budgeting, or child-care tasks and responsibilities). c. Inability to consistently maintain a safe living situation (e.g., repeated evictions or loss of housing). and 4 ministry of Health Services

15 II. Intake, Admission and Discharge Criteria and Process 3. Clients with severe and persistent mental illness who make high use of general hospital psychiatric services, specialty hospital services, tertiary level services, or psychiatric emergency services such as mental health crisis response services (i.e., greater than 50 hospital bed days) (Latimer, 1999). The primary effectiveness, and outcome measure, of ACT is usually in respect to reduction of hospital bed days. 4. Clients with severe and persistent mental illness and one or more of the following problems, which are indicators of continuous high-service needs (i.e., greater than eight hours per month): a. Intractable (i.e., persistent or very recurrent) severe major symptoms (e.g., affective, psychotic, suicidal). b. Coexisting substance use disorder of greater than six months. c. Involvement with the criminal justice system due to mental disorder, assessed at low to moderate risk in the community, and the ACT team has determined that it is able to manage the current level of risk in the community. d. Coexisting developmental disability and the ACT team has determined that it is able to manage the current level of risk especially to the client (or perhaps to others) in the community. e. Inability to consistently meet basic survival needs, residing in substandard housing, homeless, or at imminent risk of becoming homeless. f. Residing in an in-patient or supervised community residence, but clinically assessed as being able to live in a more independent living situation if intensive services are provided, or requiring a residential or institutional placement if more intensive services are not available. g. Difficulty effectively utilizing traditional office-based out-patient services. All ACT teams are encouraged to admit clients who meet ACT admission criteria or serious persistent mental illness and have other issues that would benefit from coordinated treatment, including (but not limited to): involvement with the criminal justice system at all levels (e.g., clients who have been diverted, clients on probation or parole, etc.), developmental disabilities, and substance use disorders. Ministry of Health Services 5

16 II. Intake, Admission and Discharge Criteria and Process Admission Process: Engagement, Consent AND Documentation 1. Assertive Engagement Clients who are accepted for service by the ACT team may require an assertive engagement process in order to establish a relationship with the ACT team and provide informed consent to receive treatment/ service. In the case of clients who repeatedly decline the attempts at engagement by the ACT team over time and indicate that these interventions are unwelcome, ACT teams must reassess the engagement process and establish a time frame for terminating the interventions. 2. Consent ACT clients are admitted when the team assumes responsibility for providing the treatment/service. Consent to treatment by the ACT team shall be obtained from the client personally if he or she is capable, or from an incapable client s substitute decision-maker, in accordance with applicable legislation. (Note: The term treatment is defined quite broadly in applicable legislation governing consent and would encompass many of the types of services provided by an ACT team.) 3. Documentation of admission shall include: a. The reasons for admission as stated by both the client and the ACT team. b. Signature of psychiatrist or indication of agreement to accept responsibility for the client by the psychiatrist (electronic). 4. Documentation of Service Refusal When a referral is refused by an ACT team, the team shall provide written documentation of the reasons for refusing service to the referral source. The ACT model has demonstrated effectiveness for clients in the greatest need, who are estimated to make up 20 per cent to 40 per cent of the total group of persons with serious mental illnesses. Historically these clients have not received adequate assessment and appropriate services and are typically not even being served in traditional mental health settings. Therefore, admission criteria ensure that the ACT program serves the intended client group. ACT was once considered the service of last resort when, in fact, research has shown that clients benefit from earlier access to ACT. For example, high use of acute psychiatric care should indicate need for more intensive and continuous services in the community, just 6 ministry of Health Services

17 II. Intake, Admission and Discharge Criteria and Process as intractable and severe major symptoms should indicate need for high-quality individualized assessment, intervention, and support. Both indicators of problems meriting ACT services should bring about appropriate assessment and interventions as well as compassionate and immediate support for the client and his or her family and support system. C. Discharge Discharge Criteria Discharges from the ACT team occur when clients and program staff mutually agree to the termination of services. This shall occur when clients: 1. Have successfully reached individually established goals for discharge. Program staff will arrange for transfer to a less intensive service and maintain contact with the client until transfer is complete. or 2. Have successfully demonstrated an ability to function in all major role areas (i.e., work, social, self-care) without ongoing assistance from the program, and without significant relapse when services are withdrawn (over approximately a two-year period). or 3. Move outside the geographic area of ACT s responsibility. In such cases, the ACT team shall partner with the client to arrange for transfer of mental health service responsibility to an ACT program or another provider wherever the client will be living. The ACT team shall maintain contact with the client until this service transfer is implemented. or 4. Decline or refuse services and request discharge, despite the team s intensive and persistent efforts to develop an acceptable treatment/ service plan with the client. Discharge Process and Documentation Documentation of discharge shall include: 1. The reasons for discharge as stated by both the client and the ACT team. 2. The client s bio-psychosocial status at discharge. 3. A written final evaluation summary of the client s progress toward the goals set forth in the treatment/service plan. Ministry of Health Services 7

18 II. Intake, Admission and Discharge Criteria and Process 4. A plan developed in conjunction with the client for follow-up treatment/ service after discharge. 5. The signature of the client (when possible), the client s service coordinator, the team coordinator, and the psychiatrist. Discharge to a Correctional Facility If the client is being discharged to a correctional facility, the ACT team should aim to connect with the treatment services to ensure continuity of care. Re-Admission The ACT team must facilitate readmission as a priority when required. In view of ACT s long-term commitment to its clients, the readmission process should be timely and uncomplicated. Each discharge is carefully evaluated because clients with the most serious mental illness frequently have been inappropriately discharged. Monitoring discharges is a critical program evaluation activity. ACT is a service model that has demonstrated that when services for persons with longer-term episodic disorders are delivered in a continuous rather than timelimited framework, relapse can be addressed and treatment gains maintained and improved upon. In addition, clients should not be forced out of the program prematurely. In appropriate circumstances, clients may transition to less intensive services, but arrangements must be made to maintain contact with the client until the transfer is complete. Discharges may occur when clients and program staff mutually agree to the termination of services. All too often clients are not discharged for reasons of recovery or goal achievement but are dropped due to conflicts with staff or because the complexity of the problems and issues require too much staff time. In circumstances when a client wants to fire the ACT team, it is important that the ACT team be willing to listen and to accommodate the client s wishes/preferences regarding services. If the client still requests discharge, their request must be honoured. The client should be given all necessary help to arrange alternative services and given priority for readmission to ACT if they so choose. Please Note: Some new ACT programs stop working with people whom the program fails to effectively engage and admit to the program. Problems with engagement should not be confused with reasons for discharge. Policy and Procedure Requirements: The ACT team shall maintain written admission and discharge policies and procedures. 8 ministry of Health Services

19 III. SERVICE INTENSITY AND CAPACITY The ACT programs provide intensive services to clients in community settings. The ACT Standards not only establish staff-to-client ratios but also establish the minimum number of staff required to cover the shifts, and set the frequency of staff service contacts with clients. It is important that clients who need face-to-face contact are seen personally. It is up to the ACT team to make appropriate arrangements. In locations where there is no crisis intervention service or where the service is unable to provide face-to-face contact during the hours covered, appropriate steps will have to be taken for the ACT team to implement their own system. A. Staff Coverage Each ACT team shall have a sufficient number of staff to provide treatment, rehabilitation, and support services 24 hours a day, seven days per week. Staff coverage is a different measurement of service intensity than staff-to-client ratio and probably more important to successful ACT implementation. Staff coverage gets at the critical mass of ACT staff needed to cover the 24 hours. Establishing staffing patterns (e.g., shifts, staff rotations) to regularly deliver services 24 hours a day, seven days a week ensures that clients have regular staff help when they need it; reduces client crisis; and helps reduce staff turnover. Having sufficient numbers of staff is necessary to: 1) staff two 8-hour shifts weekdays; 2) staff one shift with a minimum of two people each weekend day and holidays; 3) schedule mental health professionals to on-call duty the hours when staff are not working; and 4) have psychiatric back-up available all hours the psychiatrist is not regularly scheduled to work. It takes a minimum of 11 clinical staff for a fully funded team to provide 24/7 coverage, excluding the psychiatrist and program assistant (taking into account vacation time, sick time and staff attrition). It takes five FTE registered psychiatric nurses (or nurses with mental health experience) to be able to have one nurse on every shift. When a rural/smaller size team does not have sufficient staff numbers to operate weekday, weekend, and holiday shifts, staff are regularly scheduled to provide the necessary services on a client-by-client basis (per the client-centred comprehensive assessment and the individualized treatment/service plan) in the evenings and on weekends. The ACT team must make arrangements for crisis coverage 24/7. When a rural/smaller size team does not have sufficient staff numbers to operate an after-hours on-call system, staff should provide crisis services at least during regular Ministry of Health Services 9

20 III. SERVICE INTENSITY AND CAPACITY work hours. During all hours staff are not working, the team must arrange coverage through a reliable crisis intervention service. In this case, the rural/smaller size team communicates routinely with the crisis intervention service (i.e., at the beginning of the workday to obtain information from the previous evening and at the end of the workday to alert the crisis intervention service to clients who may need assistance and provide effective ways of helping them). B. Frequency of Client Contact 1. The ACT team shall have the capacity to provide multiple contacts each week with clients experiencing severe symptoms, trying a new medication, experiencing a health problem or serious life event, trying to go back to school or starting a new job, making changes in living situation or employment, or having significant ongoing problems in daily living. These multiple contacts may be as frequent as two to three times per day, seven days per week and depend on client need and a mutually agreed upon plan between clients and program staff. Many, if not all, staff shall share responsibility for addressing the needs of all clients requiring frequent contact. 2. The ACT team shall have the capacity to rapidly increase service intensity to a client when his or her status requires it or a client requests it. 3. The ACT team shall provide an average of three contacts per week for all clients. A contact is a meaningful occurrence that ideally takes place faceto-face. There may be instances where telephone support is appropriate. 4. Data regarding the frequency of client contacts shall be collected and reviewed as part of the program s Continuous Quality Improvement (CQI) plan. ACT varies intensity to meet the changing needs of clients with serious mental illness, to support clients in normal community settings, and to provide a sufficient level of service as an alternative to the client needing to be hospitalized to receive that level of care. This is a radical departure from how traditional services are organized. ACT services are delivered continuously and titrated, meaning that when a client needs more services, the team provides them. Conversely, when the client needs fewer services, the team lessens service intensity. 10 ministry of Health Services

21 III. SERVICE INTENSITY AND CAPACITY C. Staff-to-Client Ratio Each urban/full size team ACT team shall have the organizational capacity to provide a minimum of one full-time equivalent (FTE) staff person for every 10 clients (not including the psychiatrist and the program assistant) when at full capacity. An urban team serves a community of approximately 75,000 to 100,000 population; consideration must be taken to account for communities that are impacted by population factors such as central drift, high rates of co-morbidity or homelessness. The staff-to-client ratio may need to be adjusted in settings where the clients are consistently acutely ill, have spent long periods of time in institutional settings, are being released from correctional settings, or have complicating medical conditions that require more service contacts. Staff-to-client ratios may also need to be adjusted in settings where safety is an issue and staff must pair up to work in a particular neighborhood. However, the staff-to-client ratio should be no less than one FTE for every seven clients. Rural/smaller size teams shall have the organizational capacity to provide a minimum of one full-time equivalent (FTE) staff person for every eight clients (not including the psychiatrist and the program assistant) when at full capacity. Rural teams are appropriate for communities of approximately 30,000 population and serving a geographic area of a one-hour driving radius. In addition to the above factors that may warrant a lower staff-toclient ratio is a setting where staff must travel great geographical distances. For rural teams, the staff-to-client ratio should be no less than one FTE for every five and a half clients. Teams are accountable to the Health Authority for the number of clients served and must be able to explain the reasons for their staff-to-client ratios in terms of the above factors. Please Note: The ACT Standards define two sizes of ACT teams: 1) an urban/full size team and 2) a rural/smaller size team. Teams are not designated as urban or rural because one team is located in an urban area and the other is in a rural area. The distinguishing factor is that in a rural area there may be fewer individuals with serious mental illness who can benefit from the program. Therefore, it is not practical to have a full size team. However, if there are sufficient numbers in a rural area, the ACT program should be full size. Some British Columbia teams with rural catchment areas may indicate they have sufficient numbers to warrant a full caseload. Ministry of Health Services 11

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